65 year old male patient with involuntary movements and focal seizures

Final exam long case

January 19,2023

65 year old male patient with Involuntary movements and focal seizures 

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Date of Admission- 19/01/2023

A _65_ year old male patient presented brought to casuality by his attenders with chief complaints of Involuntary movements of left upper limb and lower limb (4:00 pm)                       

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic till  1:00 pm.

Then he had fever episode which is relieved on medication ( dolo 650)

Then  he developed Involuntary movements of left upper limb and lower limb and associated with uprolling of eyeballs , tongue bite froathing

Involuntary micturition in clothes 

No regain of consciousness between the episodes

HISTORY OF PAST ILLNESS

 H/o similar complaints in the past

13/3/2022:- seizures

Irregular medication of levipil

18/4/2022:- focal seizures secondary to hyperglycemia 

First admission was found to having high GRBS

followed by which he developed Involuntary movements upper limb and lower limb 

Old CVA 2 years back

Diabetic milletus:- 6 years - on medication ( insulin)

Hypertension:- 3 years - on medication 

PERSONAL HISTORY 

   Occupation:. Farmer

    appetite : normal 

     Diet : mixed

Marital status : married

Bowel movement  : regular      

Micturition: normal

Sleep:- adequate 

Bladder :- abnormal 

Addictions:- no

 

FAMILY HISTORY

No relevant family history 

      

GENRAL EXAMINATION 

Patient is conscious, coherent, co-operative.

There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy and edema

VITALS

Temparature:-

Pulse:- 132 beats /min 

Respiratory rate:- 24 cycles /min 

Blood pressure:- 120/60

GRBS:- 

18/1/23 :- 91mg/dl

19/1/23:- 135mg/dl

SYSTEMIC EXAMINATION:

Cardiovascular System

Inspection:-  normal on inspection

Palpation:-  all the inspectiory findings are confirmed

Apex beat felt on the 5th intercostal space

Percussion:- normal 

Ascultation:- no added sounds

Thrills-  no

Cardiac sounds- S1, S2  +

Cardiac murmurs - No

RESPIRATORY SYSTEM

Position of trachea- central

Inspection:- normal

Palpation:- all the inspectory findings are confirmed 

Percussion:- no abnormal findings on percussion 

Ascultation:-Breath sounds- vesicular

No Dyspnea and wheeze

 

ABDOMEN

Inspection:- Shape of abdomen- scaphoid

Palpation :- Palpable mass- no

Free fluid- no

Bruits- no

Liver- Not palpable

Spleen- Not palpable

Tenderness:- no

Ascultation:-Bowel sound- Yes

CENTRAL NERVOUS SYSTEM 

Patient is drowsy

Speech- normal 

Power:--

Right :---- Upperlimb :- 5/5

                 Lower limb :- 5/5

Left :- upperlimb :- 4/5

           Lowerlimb :- 4/5

Tone :-

Reflexes:-

Cerebellar signs 

Hand and nose coordination:- no

Knee and heel coordination:- no

Gait :- normal

Examination of head and neck :- neck stiffened

Investigation 

ECG: 

2d echo:- 

Tachycardia

Moderate aortic regurgitation

Diastolic dysfunction 

PROVISIONAL DIAGNOSIS:-

Focal seizures with secondary generalization 

TREATMENT

Phenytoin 100mg

Levipil 500mg

Sodium bicarbonate 500mg

Aspirin 75mg

Pantaprazole 40mg

Dolo (650)

Inj Levetiracetem 100 mg/mL